CDI - Specialist (CPC/CCS)

Greetings from Sutherland !!

HIRING Clinical documentation Specialist.

Certified Coders can apply ( CPC/CCS)

Position Summary:

The ED CDI Specialist is responsible for enhancing the quality and accuracy of clinical documentation in the Emergency Department to ensure compliance with regulatory standards, optimize reimbursement, and improve patient care outcomes. This role involves collaborating with coders, auditors, clients, physicians and other healthcare providers to ensure that documentation reflects the true clinical picture of patients' conditions and treatments.

Key Responsibilities:-

• Documentation Review: Perform regular audits of clinical documentation in the ED to identify areas for improvement, ensuring accuracy and completeness of report.
• Education and Training: Provide ongoing education and training to ED staff on best practices for clinical documentation, including coding guidelines and regulatory requirements.
• Collaboration: Work closely with Coders/QA staff/Leadership/Clients, ED physicians and clinical staff to clarify documentation issues and promote accurate coding and reporting.
• Data Analysis: Analyze documentation trends and outcomes to identify opportunities for improvement in clinical practices and documentation accuracy.
• Compliance Monitoring: Ensure adherence to CMS guidelines and other regulatory requirements related to clinical documentation.
• Feedback and Reporting: Develop and present reports on documentation improvement initiatives and outcomes to immediate supervisor, stakeholders and Senior leadership.
• Quality Improvement: Participate in quality improvement initiatives aimed at enhancing patient care and safety in the ED.
• Professional Development: Stay current with developments in clinical documentation and coding standards through continuing education and professional organizations.

Qualifications:-

• Education: Masters/bachelors degree in any life science stream Medicine, Physiotherapy, Occupational Therapy, Physician Assistant, Nursing, Pharmacy, Biomedical, Biochemistry, Microbiology, health information management, or related field.
• Experience: Minimum of 2 years of clinical experience in an emergency department setting, with at least 2 years in clinical documentation improvement or coding.
• Certifications: CPC, Certified Clinical Documentation Specialist (CCDS), Certified Documentation Integrity Practitioner (CDIP) or equivalent certification preferred.
• Skills: Strong knowledge of medical terminology, anatomy, physiology, coding guidelines (ICD-10, CPT, Modifiers, Category II codes), and clinical documentation standards with Excellent communication, analytical, and problem-solving skills.
• Technology Proficiency: Proficiency in electronic health record (EHR) systems and clinical documentation improvement software.

Work Environment:

• Primarily in the Emergency Department with interactions across various departments.
• Ability to work in a fast-paced clinical environment in a US shift time zone.

Work from office is mandatory

Interested Candidates can share your resume to Sunilkumar.r1@sutherlandglobal.com/ 91-7200243068